ED management : the monthly update on emergency department management
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To make a big dent in adverse drug events (ADE), Nationwide Children's Hospital devised medication huddles: a process that takes place after every reported ADE. A core huddle team meets with clinicians from the specific unit involved to discuss why the ADE occurred, and what can be done to prevent future events. In three years, the approach has reduced ADEs by 74%, and the rate of ADEs per 1,000 dispensed doses has decreased by 85%. * Administrators say a safety culture that encourages error reporting is key to making the process work. * To facilitate the huddle discussions, developers created a data collection tool that prompts huddle participants to describe the ADE, what factors were involved, and potential solutions. * While the medication huddles were first implemented in the hospital's critical care units, the process has since been expanded to include all areas of the hospital, including the ED.
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In a continuing effort to ease demand on busy EDs, some communities are coming up with new ways to leverage paramedics. Under a three-year pilot program in Raleigh, NC, a select group of paramedics with added training are being used to assess patients with mental health or addiction problems and transfer them to alternative facilities when appropriate. In Robbinsdale, MN, a community paramedicine program is filling in care gaps for patients with chronic diseases and other complaints who are at risk for repeat ED visits or inpatient hospitalizations. * Administrators of the Raleigh, NC, program say that in 2013, paramedics diverted more than 300 patients to alternative facilities. Of these, only 20% to 25% need further transport to the hospital. * Every time the NC paramedics divert a patient from the ED to an alternative facility, they return an estimated 14 bed-hours back to the ED. * In addition to responding to patients with non-urgent needs, the Robbinsdale, MN, community paramedicine program is a referral source for ED physicians who are concerned about follow-up care for patients who have presented to the ED with medical problems that require ongoing attention.
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A new study suggests that introducing palliative care consultations while patients are still in the ED, rather than waiting until after patients have been admitted, can significantly reduce inpatient length of stay. Experts say the approach may also improve quality of care while patients are in the hospital, and do a better job of meeting patient goals. *Researchers analyzed 1,435 palliative care consults, including 50 that took place in the ED over a four-year period. They found that consultation in the ED was associated with hospital stays that were 3.6 days shorter, on average, than the hospital stays of patients who received palliative care consults following admission to the hospital. * Palliative care typically includes an extensive goals-of-care discussion with patients and families, symptom management, and other services focused on meeting patient needs and improving quality of life. * Experts say the top four groups of patients who can benefit from goals-of-care discussions are patients with metastatic cancer, advanced congestive heart failure, advanced chronic obstructive pulmonary disease, and advanced dementia. *ED administrators interested in making improvements in their approach to palliative care should perform a needs assessment, forge partnerships with community resources, and identify a champion, according to palliative care experts.
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Diabetic patients who lack access to primary care tend to frequent the ED, often with complications from their disease that could have been prevented with proper management and education. To get around the problem of access, researchers tested an automated program that continuously delivered educational messaging via text to a group of patients who presented to the ED with poorly controlled diabetes. After six months, researchers noted improvements in Hb A1c levels, self-reported medication adherence, and ED utilization when compared with a control group. ⋯ There were also medication reminders, healthy living challenges, and trivia questions about diabetes. At six months, Hb A1c levels decreased by 1.05% in the intervention group, compared to 0.60% in the control group, and self-reported medication adherence improved from 4.5 to 5.4 (as measured on an 8 point scale) in the intervention group versus a decrease of 0.1 in the control group. During the six-month study period, 35.9% of patients in the intervention group presented to the ED for care, as compared to 51.6% of patients in the control group.
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To gather insight on an array strategies used to curb ED utilization, investigators conducted a systematic review of five types of interventions that are based outside of the ED: patient education, patient financial incentives, the creation of additional non-ED capacity, pre-hospital diversion, and managed care. While the available evidence showed that all of the interventions had some impact on reducing ED utilization, researchers caution that there was scant data showing what impact these interventions had on outcomes or safety. Investigators found that patient education interventions were associated with the greatest magnitude of reductions in ED use, but they stress that the interventions reviewed were very heterogeneous. ⋯ They were effective at reducing ED utilization, but investigators caution that policy makers need to consider the potential impact on outcomes. There was some evidence that creating additional non-ED capacity fueled demand for care, but had a small impact on ED utilization. Going forward, emergency providers need to fully engage in any discussions about ED utilization and demonstrate the value that EDs bring to the health care system, say experts.